Greater occipital nerve iatrogenic neuroma after cervical arthrodesis: high-frequency ultrasound findings and ultrasound-guided management

Persistent occipital headache after cervical arthrodesis is a disabling complication, often due to iatrogenic injury to the greater or lesser occipital nerves. Clinical overlap with primary headaches may delay diagnosis. High-resolution ultrasound (HRUS) has emerged as a reliable tool for evaluating superficial peripheral nerves and postoperative changes. We report a case illustrating its diagnostic value in occipital nerve injury, with a focused review of sonoanatomy. A 45-year-old woman developed refractory bilateral occipital pain consistent with occipital neuralgia after cervical arthrodesis for disc herniation. HRUS (24 MHz) using a standardized protocol revealed postsurgical changes and focal fusiform thickening with loss of fascicular architecture of the right greater occipital nerve at its muscular perforation site, consistent with iatrogenic neuroma. These findings guided targeted management. This case underscores the diagnostic challenge of postsurgical occipital neuralgia and the utility of HRUS. Knowledge of occipital nerve sonoanatomy and its relationship to adjacent cervical muscles is essential. HRUS enables real-time evaluation of nerve morphology and continuity, detecting focal thickening often missed by other imaging methods. HRUS allowed diagnosis and percutaneous treatment of greater occipital nerve neuroma in this patient.